Intake Form

Questions asked will help to determine if Midwifery care is the best choice for you and your Baby. Please fill out information as is on your Health Care Card as Midwifery care is covered by your BC Care Card.

First Name*

Last Name*

Health Care #*

Address*

Postal Code*

City*

Phone (Home)

Phone (Cell)

Phone (Work)

Birth Date*

DD

MM

YYYY

Email*

Partners Name

Partners Phone

Best Method to contact you?*

Home Phone

Cell Phone

Work Phone

Email

Is this your first Child?*

Yes

No

If no, How many other children do you have?

Are you a previous client?*

Yes

No

If you are uncomfortable answering any of the questions below, they can be covered privately with your Midwife.

Do you take Medications?

Yes

No

Do you want a___

Hospital birth

Home birth

Undecided

Brief Medical History (Include any health concerns)

Obstetrical History

Normal

Yes

No

Complications

Yes

No

Caesarian Section

Yes

No

Date of last LMP*

DD

MM

YYYY

Expected Due Date

DD

MM

YYYY

First Name*

Last Name*

Health Care #*

Address*

Postal Code*

City*

Birth Date*

DD

MM

YYYY

Phone (Home)

Phone (Cell)

Phone (Work)

Email*

Partners Name

Partners Phone

Best Method to contact you?*

Home Phone

Cell Phone

Work Phone

Email

Is this your first Child?*

Yes

No

If no, How many other children do you have?

Are you a previous client?*

Yes

No

If you are uncomfortable answering any of the questions below, they can be covered privately with your Midwife.

Do you take Medications?

Yes

No

Do you want a___

Hospital birth

Home birth

Undecided

Brief Medical History (Include any health concerns)

Obstetrical History

Normal

Yes

No

Complications

Yes

No

Caesarian Section

Yes

No

Date of last LMP*

DD

MM

YYYY

Expected Due Date

DD

MM

YYYY

The material on this website is intended for information use only. Any individual with health concerns should contact their health care provider for a complete diagnosis. Do not depend solely on the content of this website for treatment.